(Courtesy of Mario Purisic - Unsplash)
In so many ways, we’re all in this COVID-19 disaster together. What each of us does either protects or puts others at risk. These concentric circles of individual choice radiate through each U.S. county and state, the nation and the world. It’s like raindrops falling on a still pond, at first the ripples barely intersecting. Then it rains harder, drops becoming sheets, splashing the surface into waves. Unfortunately, we have tested so little we actually don’t know the scale of our storm, and we are guessing where the rain will become a flood. In many states, only people sick enough to be potential hospital patients are encouraged to get tested. I have four family members in California sick with COVID, and not one is in the official count. It makes you wonder where the truth lies.
I get kind of seduced by the daily COVID statistics even though they tell us only about the small subset of people who have access to testing. For a while I thought that if you multiplied the official caseload on the Johns Hopkins or New York Times websites by 10, you might get a sense of the actual number of people with COVID. Then I ran into a Swedish study using data from The Lancet Infectious Diseases. It woke me up from that dream. These data suggest that on average only 6% of cases have been identified worldwide. We may be dealing with tens of millions of cases internationally instead of the 1.4 million reported today. Even more striking, the U.S. is lagging behind other countries. The Swedish study suggests that confirmed COVID cases in the U.S. may be only 1.6% of our actual total. The possible silver lining is that we could have a lot of people with newly-minted antibodies, as many people have already recovered or are currently getting well. But the truth is we have no idea where we stand, do we?
Population-level information can feel both overwhelming and strangely abstract. In contrast, each of us is alone in our unique human body. We may have the benefit of youth and health. But no matter how hard we try, some of us are at elevated risk of severe illness or death if we catch the virus. Variables include sex, age, pre-existing health conditions, government policy where we live, whether we are victims of institutional racism, and poverty.
In the world of COVID-19, men are more likely to end up with severe illness than women. Here in Colorado, there are more slightly women with medically diagnosed COVID cases, but 62% of our dead are men. This ratio is true for other states as well. At first, people about the gender-skewed death statistics from China: “It’s because more men smoke there.” Then it became clear that significantly more men than women were being admitted to ICUs or dying in Italy, Spain, France, Norway, and Great Britain. Something else is going on. Scientists have tried to figure out the why of the gender disparity. They have come up with various hypotheses related to X chromosomes, estrogen, behavioral differences and, most telling of all, immune system differences.
Then there’s age. Almost since the beginning of the coronavirus epidemic, we have been warned that older people are more vulnerable, but we aren’t always told why. The main answer is: less robust immune systems. There’s even a word for it – “immunosenescence”, the deterioration of our immune systems as we age. One immunobiologist calls aging “the twilight of immunity.” Our immune defenses --- the leukocytes, antibodies, and ‘naïve’ T cells, meaning the ones with no memory of past illness and whose job it is to fight new invaders – are fewer in number and just can’t do what they used to do for us. Here again there’s a sex advantage for women: they have more antibody-producing B cells, more invader-repelling T cells. What men get, alas, is more cytokine-producing cells. Cytokines help our immune system organize our defense against pathogens. But they can end up like an accelerator pedal stuck to the floor, keeping the immune system revved too high and for too long. These cells can cause the dreaded “cytokine storm”, a dramatic immune system overreaction. Our precious immune systems may attack our vital organs, damaging them and sending us into sepsis or other lethal shut down. It’s a poignant paradox when the system that is supposed to protect us kills us.
Our biological age is not our fate. Even if we are fairly old, we may have good immune systems. A 50-year-old with diabetes can be at greater risk than an 80-year-old who takes walks every day. The fewer underlying conditions we suffer from the better. In the case of COVID-19, conditions that put us at particular risk include diabetes, hypertension, lung disease, heart disease, and kidney disease. Being obese is also a risk factor. The people of the American South have more of these underlying conditions, and are consequently at greater risk. Those who live in states without Medicaid expansion and with lower per capita public health spending are more vulnerable.
It’s hard to unpack the relationship between race, health status, and poverty, but there’s disturbing data about black Americans dying of COVID at a higher rate than white Americans. There are many recent examples, but here’s one: Milwaukee County, Wisconsin. Black people make up only 26% of the population, but have suffered 81% of the COVID-19 deaths.
There are thus many factors that make COVID not an equal opportunity illness, including the effects of poverty – population density, air pollution, crowded housing where there’s no way to self-isolate, food deserts, and poor access to health care. Low-income people are likely to be the ones taking care of those of us huddling in our comfortable houses. They are the grocery store clerks (who are now dying), the food delivery workers, the ones who provide home to frail elderly people. There are of course also the front-line health care workers, and I appreciate them every day.
Underneath the statistics and the biology, there’s each one of us, struggling for safety and wellness. We’re in our separate bodies, suspended in the rain cloud. Then one by one, some of us hurtle through the atmosphere, symptomatic or asymptomatic but nonetheless infected with COVID. If we’re fortunate to survive the fall, we pool on the earth below, another drop in what may become a sea.
I get kind of seduced by the daily statistics even though they tell us only about the small subset of people who have access to testing. For a while I thought that if you multiplied the official caseload on the Johns Hopkins or we gather will, in time, show us how to rebuild and to heal.